The Technique of the Transfer

It’s an irony of Complex Rehab Technology (CRT): Seating team members who give their all to create a functional seating and mobility system must also ensure the client can leave that system safely and efficiently.

Young girl asleep in bed

Istockphoto.com/Milos Dimic

“It’s obviously a very relevant subject,” said Brad Peterson, VP of U.S. Sales for Amylior. “People should be transferring at least two times a day, and studies have found that some folks are transferring 15 to 20 times a day. Obviously, not all of those transfers are to and from bed. There’s bed, there are commodes and tubs, there are work surfaces and multiple environments. So any time you look at transfers, you should be looking at more than just one surface and more than just one place.”

Unique Techniques Required

“Everybody’s different,” Peterson said regarding clients’ transfer-related abilities, strengths and preferences.

Catherine Sweeney, PT, ATP/SMS, Regional Clinical Education Manager for Permobil, has spent most of her 30-year career in acute rehab, “which is where my passion for wheelchair seating began. That’s where the deep dive of all the details that go into making transfers successful happened.”

Sweeney learned that if people who use wheelchairs aren’t set up with the optimal equipment or aren’t taught how to transfer safely, they will transfer nonetheless… sometimes, dangerously.

“They end up compensating,” Sweeney said. “In some way, shape or form, they’ll get to that surface, hopefully. But the compensation is that they’re overpulling, they’re extending their arms to the point that they’re in a vulnerable position, and then their wrists are pulling their body weight.”

She added that poor transfers can have devastating results, including falls and other injuries: “Especially when a device isn’t configured with transfers in mind: You can get your feet tangled in a legrest that doesn’t swing away when it should have. Or maybe the tapered front end of an ultralight is too tight for foot placement. So what happens is you do your spinal-cord type of transfer, but your foot doesn’t have room to rotate as your body does, and the next thing you know, you’ve got a spinal fracture of your tibia or some type of soft tissue damage at your knee because you turned, but it didn’t.”

Power Chair Transfers: Powered Seating Is Key

The powered seating functions often seen on CRT power chairs can facilitate transfers, Peterson said. “I think elevate, anterior tilt, and what we call anterior assist are all excellent ways to facilitate a standing transfer, whether it be independent, an assist to stand-pivot or a sit-to-stand. Sit-to-stand transfers are incredibly hard on not only the users, but also the caregivers, whether those be family members, spouses, nurses or aides.

When you elevate someone, what you’re trying to do is get those femurs and hips in a downhill orientation to let gravity assist with the transfer. And possibly to use the strength someone could have in their thigh muscles or in their legs to facilitate the transfer. So the ability to transfer from a different height is important.

“Anterior tilt can do that as well: You’re opening the hips as you’re lowering the feet. It’s almost like a seat lift chair: It’s lifting you out of the chair and pushing your backside forward. A lot of times people don’t need that full 45° of anterior tilt, hence some of the different degrees that you see from some manufacturers these days, which I think are beneficial. You’re moving someone forward as well as up, so you’re moving their reach forward.”

Additionally, power chair components can help with transfers to give clients extra support. “For some folks who still have the ability to do a little bit of a weight shift or to scoot to the edge of the seat, or for someone who has [a caregiver] to help them scoot to the edge of the seat, sometimes just getting the footrest out of the way is a big idea as well,” Peterson said. “We get a lot of requests to power down a foot platform to get that foot platform or footplate on the ground so they can transfer without having anything in front of them or without having to clear something, in terms of a front rigging.

“Then you start to look at all the ancillary parts of the chair. I’ve got someone forward, I’ve got their feet on the floor — now what are they pushing off of? How are they or someone else getting them to a standing position? We see all too often people who are pushing down on their swing-away joysticks. That joystick and that arm take a beating. So that’s why you have transfer handles and different types of armrests and surfaces to help with that reposition or that transfer.”

Perhaps one of the biggest potential advantages that powered seating offers is the ability to easily adjust a client’s seated height according to the transfer situation. “Downhill is usually a much easier way to transfer,” Peterson said. “Transferring from an elevated seat to a slightly lower bed is much easier. We’ve done systems in the past in which you have an elevated seat, and when it’s all the way down, the chair is lower than the bed, but when it’s up, you’re able to transfer downhill from the chair to the bed. Same thing with your commodes or your tubs.”

But seat elevation doesn’t solve every transfer dilemma. “It’s not the only consideration,” Peterson noted. “Is it a straight transfer? Is it a side transfer? Is it one in which someone will have to rotate? You’re looking at what side your joystick is on in terms of how they’re going to pull into a surface to transfer. Maybe it just means someone is going to back into a transfer position instead of pulling forward. It’s wheelchair skills and driving, as well.”

Peterson recalled working with a client who had a bathtub-related request: “We had to get his footrest to retract in so he could pull up to his tub. Then he could independently put his feet into the tub and do a safe transfer onto his bench. Otherwise, he’d have a huge gap [between chair and bench]. He had a history of falls, and he didn’t have caregivers every day. So we looked at the transfers he had to do on his own on a regular basis to make them as safe as possible.”

Every situation is a little different, depending on the client’s physical abilities, the availability of caregiver assistance, and the environment of the transfers. “We’ve had people use lateral tilt for transfers as well,” Peterson said. “We [worked with] someone who elevated and was able to do almost a full recline. And that way, they rolled into bed. Granted, that’s not everyday. But they went from an unsafe, very time-consuming transfer to a very easy, safe transfer. It was something that while it was a little costly and a little different, it was able to be justified based on taking videos of how they transferred previously and how it made their transfers easier and safer.”

Manual Chair Transfers: Placement & Position

Clients who use ultralightweight wheelchairs might have greater physical abilities than power chair users do, but they can’t benefit from the assistance of powered seating functions.

“Manual wheelchair transfer success depends on the clients’ deficits that need to be considered,” Sweeney said. “In general, higher surface to lower — or at least level — is the goal when weakness is involved or a transfer board is in use. It is tricky because the height of the wheelchair surface cannot be adjusted on the fly, as in the case when using a power wheelchair with tilt or seat elevation. So when evaluating the wheelchair, every surface height in the home needs to be pulled into the equation when making final selection of wheelchair frame and seat cushion. Having the measurements of each transfer surface in the home is essential, as well as knowing what can be adjusted and helping the consumer know how to adapt surfaces.”

Sweeney said placement of the wheelchair plus preparation are crucial: “Positioning the chair as close to the transfer surface as possible; locking the wheel locks; removing/flipping back the armrests; and correct placement of the feet are key. If using a sliding board, the seat cushion surface needs to be considered, as well as the transfer practiced, to ensure the person knows how the sliding board position or technique needs to be adapted.”

A transfer assessment should include examining the client’s functional abilities, which will vary from person to person, Sweeney said. “Ultralight manual wheelchairs include a wide variety of people with a wide variety of deficits, because efficiency and configuration are essential for anyone using a wheelchair as their primary mobility device. Thus, this includes many people: Users status post cerebrovascular accident, amputation, traumatic brain injury, spinal cord injury, multiple sclerosis, etc. For each person, we base the transfer technique on what skills exist and when deficits need to be compensated for.

“For example, a client with poor balance would be instructed on a transfer during which they are always in contact with stable surfaces and never are letting go fully (i.e., hand on bed, and other hand remains on the wheelchair armrest, low pivot). The technique for a client with spinal cord injury would change depending on the level of injury: Clients with lower injuries are usually successful with depression-style ‘push-up’ transfer techniques, while clients with higher injuries may start off with a sliding board and progress to a depression-style transfer. In general, the key elements remain: wheelchair position and parts prep; hand and foot/feet placement; and head/hips relationship to maximize weight shift.”

Techniques & Tune-Ups

Another potential transfer complication is that equipment and techniques that work well earlier in a wheelchair user’s life can lose their efficiency as clients age and their bodies change. For example, after years of self propelling and transferring, ultralightweight users could experience shoulder wear.

“Because of that population being so vulnerable, that shoulder being so vulnerable, I always start by watching the person transfer,” Sweeney said. “That’s when I decide, ‘This person needs a tuneup.’ Or this person can transfer successfully: They’re not shearing, but they’re putting themselves in a very vulnerable position for injury. They’ve been doing it a long time, and they’ve been getting away with it.”

Sweeney said she asks about daily routines: “I try to ask each person what they do, other than transfers, in their daily life for their body and for strengthening. Folks are overworking the anterior muscles of their shoulders and chest, and their posterior muscles become overstretched. If you’re not working on them, that scapular position ends up protracted and forward and dumping their shoulder joints. So I try to do education about posterior structure strengthening: stretching the front, strengthening the back, and why. And basically saying yes, you’re successful now, but you have decades more. We need to make sure your shoulders are there for you throughout everything.”

Peterson emphasized that transfer routines need to be re-evaluated regularly to determine if adjustments are needed. “We tend to look at certain diagnoses, like spinal cord injuries, and think their capabilities are either going to get better or they’re going to get worse. A lot of folks are in a steady state and have been transferring the same way for 15 or 20 years. So you don’t take any of that away or change it.”

Sweeney said evaluating transfer routines is ongoing, ideally. “A lot of people think wheelchair prescription is one and done, or two visits and done,” she said. “It’s so complicated that if you’re doing it well, it’s at least four visits, especially in home health. I encourage [the seating team] to make it a long conversation, not necessarily to increase utilization, but to make sure [client] needs are met. Every person who uses a wheelchair, whether you’re seeing them for the wheelchair or not, is a [situation] that you should be thinking about the wheelchair. If it’s a person with a stroke, and you’re working on therapeutic gait, and they use a wheelchair, look at the wheelchair setup, look at their education about their arms or about their bodies and their posture in the chair. It is complicated. Shoulder health over time is part of what we should be looking at with every new intervention.”

And she also wants clients to view their seating team as an ongoing resource. “I don’t think most folks, especially those coming in with a progressive diagnosis who finally need their first chair, realize the role of the team. I need to have [the client] on my radar and I need to be on their radar on a semi-regular basis, whether it’s once a year or once every five years, depending on what crops up. Just imparting that: This is what we do, and this is what we are here for, to make sure you are mobile and independent and your posture is supported and you’re comfortable and you’re functional. So come back if there are issues.”

Peterson extends that education to the caregiver. “It’s educating the consumer, but it’s also educating their caregivers,” he said. “I worked in a state hospital in Massachusetts and in different places, and every caregiver is different. With a lot of caregivers, if [a component] doesn’t swing away, they’re going to make it swing away, whether that means breaking it or not. So in designs, in education, make sure they know how to swing it away, how to put it back on, how to store it. Do you want something that’s removable, like an armrest? Because that’s how things disappear. Or do you want something that flips back?”

Clients and caregivers change, Peterson pointed out. “Transfers should be reassessed, because it’s going to take a toll on the caregiver. We see it with kids: As our young friends with cerebral palsy and muscular dystrophy get older, they get bigger. Our function changes, our shape changes. We’re not static beings.” Peterson recalled creating a power flip-down transfer arm, an armrest that flips down to serve as a transfer board and bridge the gap between the chair and another surface. “It’s every day,” he said of the need for creative transfer solutions. “All the providers and therapists have to do is ask. What do you want to do? We can do that.”

This article originally appeared in the August/September 2020 issue of Mobility Management.